Provider Demographics
NPI:1053316687
Name:FORNEY, NICOLE M (OD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:FORNEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1130
Mailing Address - Country:US
Mailing Address - Phone:610-376-1981
Mailing Address - Fax:610-376-3153
Practice Address - Street 1:2630 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1130
Practice Address - Country:US
Practice Address - Phone:610-376-1981
Practice Address - Fax:610-376-3153
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001274152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018674770001Medicaid
071907Medicare ID - Type Unspecified